Manager of Quality and Safety

About the Role

The Manager of Quality and Safety is responsible for managing quality and safety programming at the local ministry level. This role involves collaborating with the ministry’s executive team, leadership, providers, and colleagues to cultivate high quality standards and achieve outcomes. Key responsibilities include leading and implementing quality and safety strategies, overseeing quality, patient safety improvement, culture of safety (TogetherSafe), and infection prevention departments.

The Manager reports directly to the MercyOne RHM Director of Quality and Safety of Hospitals, with an indirect reporting relationship to the local Chief Medical Officer (CMO) or President in the absence of a CMO.

Responsibilities

• Leads and manages quality, patient safety (including culture of safety initiatives), and infection prevention with high reliability principles aimed at zero harm.
• Implements a quality performance improvement plan meeting CMS and The Joint Commission (TJC) regulations, in collaboration with executive teams, leadership, and committees.
• Collaborates with leadership, providers, and nursing staff to develop and implement quality and safety strategies for high-quality patient outcomes.
• Provides direct supervision, development, and competency assessment for quality, safety, and infection prevention staff.
• Leads or participates in quality and safety committees, identifying focus areas and addressing findings proactively.
• Drives continuous improvement in CMS value-based programs, pay-for-performance initiatives, and TJC regulatory compliance.
• Works toward achieving recognition from external rating organizations (e.g., CMS, Leapfrog, Healthgrades, Blue Distinction).
• Collaborates with accreditation, risk management, customer experience, and performance excellence teams to support improvement initiatives.
• Develops quality excellence systems integrating LEAN and other data-driven methodologies.
• Provides oversight and consultative services for quality improvement teams, including project design and data tool development.
• Improves the culture of safety, supporting "Just Culture" and "TogetherSafe" initiatives, and conducting cause analyses (e.g., root cause, HFMEA, PSO).
• Oversees clinical data gathering and analytics, ensuring accuracy of scorecards and dashboards for internal and external stakeholders.
• Promotes shared leadership and decision-making.
• Maintains knowledge of applicable federal, state, and local laws, Trinity Health’s Organizational Integrity Program, and ethical standards.
• Supports evidence-based practice, innovation, and research, and participates in the clinical contracting process.
• Contributes to evaluating medical staff performance, including focused and ongoing professional practice evaluations.
• Stays aware of and responds to issues such as cultural diversity, political and social influences, economic factors, and ethical healthcare concerns.
• Performs other duties consistent with the role as directed.

Requirements

• Bachelor’s degree in nursing, health administration, or a related field (Master’s degree preferred).
• Iowa licensure as a Registered Nurse.
• Minimum of five (5) years of hospital experience in quality and/or safety, preferably in a progressive leadership or manager-level role.
• National certification in quality/safety required within two years of hire.
• LEAN Six Sigma certification preferred.

Skills

• Member of a professional nursing organization.
• Expertise in performance improvement methodology and tools.
• Proficiency in computer applications, including Microsoft Office Suite (Word, Excel, PowerPoint, Outlook), HealthStream, and reporting tools.
• Experience with event reporting systems, government reporting systems, and electronic health records (e.g., PowerChart/EPIC).